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Waste Tire Su, vey & Inspection Repor ., Inspection Report Number <br /> State of California <br /> CalRecycle I 1 - 1255821 <br /> CalRecycle 181(Rev. (Cal Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- O � � � � Inspection Type(Fill one) <br /> Site Suffix: 0 Routine Q Re-inspection O Referral Q Observation <br /> Local �� If Referral,choose referral type(Fill one) <br /> Identifier: X70.vs, 1 Gw� Q CHP Q CalRecycle Q Complaint Q Educational Visit 0 Other <br /> Business or Facility Name �V A^`l/ — Inspected By Inspector <br /> Gv V 2V`t Z^� - lc � l/xLW'_ GUC� /' 'C \b� G� - ' 1 mA 1-7 V <br /> Physical Address 1 <br /> 37-56 1) Uwsovl <br /> S�r��� �� �SZoS Inspection Date O ` � 2- 7 fl ) S <br /> J Time In Time Out <br /> Business Rep Title c 0 AM 7 C 0 AM <br /> SQ Vl 6�ttC2 - ' J O PM J & PM <br /> \ Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 9 Active a Passenger 0 Generator * Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O Q Inactive O Truck <br /> Longitude - Q Planned Q OTR O End-Use Q Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer 0 Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension <br /> O 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O Q PRC§42956-Registration/Decal in Vehicle <br /> Q O 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date <br /> M / m / m <br /> 0 O 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> 0 O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE N <br /> O O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> Q O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators 10 In Compliance-No Violations o <br /> O 0 Other:§ t <br /> Comments <br /> K-cs�1�v2 �C; <br /> Inspection Form Included: Q <br /> Comments Included: 4 <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> �,( 62081 <br /> INSTRUCTIONS ON BACK Correct: incorrect: \/ W NJ E X A M P L E 1111 <br /> 1 2 3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA © ■ <br />